Ventral Hernia Repair in the Obese Patient

Diego Camacho MD FACSAssociate Professor of SurgeryDirector MIS and Endoscopic SurgeryAlbert Einstein College of MedicineMontefiore Medical Center Bronx NY

Disclosure

NO HABLO INGLES MUY BIEN!!!!!!

Run or Not to Run

Ventral & Incisional Hernia

• More than 2 million open abdominal operations are performed annually in the U.S.

• 2 – 11% of these patients will develop incisional hernias.

• Approx. 350,000 ventral and incisional hernias are repaired each year in the U.S

What is the Problem

• Hernia patients and obesity

Symptomatic vs Asymptomatic

• Bariatric patients with hernia

Pre OP Considerations

• Can the repair be delayed?

• What is the best surgical approach

• Bariatric Surgery

• Does the pt wants and qualifies?

Concurrent vs Staged

Bypass/Sleeve/Balloon/Band

• Expectations of the repair

Obesity and Ventral Hernias

• Technical Challenges

• Medical Conditions• Compromise Tissue handling

• Wound Complications

Does Obesity Matters

• Commonly cited factor for recurrence

• Technical difficulties

• Large defects Large Mesh

• Peri-OP complications

– Surgical site

– Systemic

Where is the DATA??

Does Obesity Matters

• Retrospective review

• 168 pts 42 pts with BMI >35

• Standard LVHR (synthetic mesh)

• 19 month F/U 12% recurrence

• Influence by defect/mesh size

Comparison of early outcomes for Lap VH between obese and non-obese parientsChing et al, Surg Endoscopy 2008

Does Obesity Matter

• Retrospective review– 27 pts >BMI 35

– Mean BMI 47

• Standard LVH– Synthetic 53%

– Biologic 47%

• 15 month F/U Recurence 18%

• Higher recurrence and pts need to be infromed

Outcomes of LVH in Morbid Obese patientsRattoupuolus et al. Surg Endo 2008

Does Obesity Matters

• 2 year retrospective review

• Retrospective review

– Group I (n=134) BMI >40

– Group II (n=767) BMI <40

Group I 8.3% recurrence

Group II 2.9% recurrence

Laparoscopic VHR between morbid obese patientsTseretell et al, Hernia 2013

Recurrence After Laparoscopic Ventral Hernia Repair in Obese Patiens

• 850 pt eval

– Patients with BMI>40

• Younger (47 vs 57 yrs), p<0.01

• Female, p<0.01

• Large defect size (167 vs 105 cm), p<0.01

• Trend to have more complications (18% vs 16%), p=0.09

• Four times more likely to have a recurrence

(7.8% vs 2%) p<0.05

Heniford et al Annals of Surg 2003

Why This High Recurrence Rate in Obese Patients

PATHOPHYSIOLOGY

Friedenberg et al. Am J Gastroenterol 2008;103:2111-2122)

IAP of Normal and Obese Patients

Activity Normal Obese

Stairs 69 (40-110) 88.3 (55-129)

Arm Curl 25 (17-37) 64 (16-100)

Bench Press 7 (2-34) 22 (5-35)

Cough 81 (40-127) 155 (80-250)

StandingCough

107 (64-141) 185 (80-255)

Jumping 171 (43-252) 212 (150-25)

American Hernia Society 2006

What Can We Do to Reduce the Incidence of Hernia

Recurrence

Choice of Strategy

• Depends on the Patient and the Surgeon

– Symptoms

– Urgency of the procedure

– Best surgical approach

– BMI of patient

– Amount of weight loss desired

– Comorbid conditions

Medical Treatment

• Diet – low in calories, fat and carbohydrates

• Exercise– 40 minutes 5 times per week

• Behavior Modification – eat 3 sensible meals

per day, avoid snacking

• Drugs/Prescription medications

Stimulants/appetite suppressants

• Antidepressants (Meridia®)

• Reduce fat absorption (Xenical®)

Diet

• Optifast or other diets

• Limited calories (900-1200 Kcal/day)

• Can achieve 15-25% weight loss in short period of time

• Nutrition evaluation 1-2 month

• High Cost

Disadvantages

• Most patients (95-97%) regain most or all of

the weight that was lost within 2-5 years

following diet or drug treatment

The average amount of weight loss is

relatively small 10-40 pounds

• Drug therapy may be associated with

severe complications (Fen-Phen and heart

disease).

Exercise

Which Technique

• Primary repair? (high recurrence 15-35%)

• Open VHR– Simple onlay vs inlay

– STOPPA

– Component separation

– TAR

Laparoscopic VHR

Staged Procedure

LVHR in the Obese PatientNew standard of care?

• Retrospective review

• 163 patients

• BMI 38 (range,30-67)

• Standard LVHR (3%conversion)

• 25 months follow up

• Recurrence 5.5%

• “LVHR may be the approach of choice”

Novitsky et al, Archives of Suregry 2006

Contraindications to Laparoscopy

• Loss of Domain

• Very large (>20cm) defect??

• Past or present mesh infection

• Need to remove old mesh

• Skin changes over the hernia sac

Open Component• Retrospective Review

• 30 pts, BMI >35

– Mean BMI 60

– Mean defect width 12 cm (3-55)

– No mesh placed Anterior CS

• Additional procedures– RYGBP in 6 (20%) pts

– Intestinal resection in 6 (20%) pts

– Panniculectomy in 16 (53%) pts

Autologous tissue reconstruction of Ventral Hernias in Morbidly ObeseE. Chand et al, Arch of Surgery 2007

Open Component

• 44 month F/U

• Recurrence 3%

• Conclusions

– Comp Separation is safe

– Performance of panniculectomy does not improve outcomes

– Effective technique

Stoppa

• Retrospective Review

• 90 pts BMI>30– Mean of 40

– Retromuscular (STOPPA) repair

– Synthetic mesh as sublay

– Outcomes• Morbidity 8%

• Mortality 1.1%

• F/U 50 months Recurrence 5.5%

Moore et al, The American J of Surgery

SHOULD VHR BE DELAYED IN MORBIDLY OBESE PATIENTS

Staged Repair

• Staged Ventral Hernia repair after surgical weight loss may decrease perioperative complications and recurrence rates in Obese Patients

Comorbidity Resolution after Weight Loss Surgery

Staged Repair

• Restrospective Review

• 27 pts

• Mean BMI 51

• Gastric Bypass

– Open 22, Lap in 5

– Concurrent Hernai Repair (n=7)

• Primary 4

• Biologyc mesh in 3ALL Recurred

Staged hernia repair preceded by gastric bypas for the tretment of the morbid obese with complex ventral herniaNewcome et al, Hernia 2009

Staged Repair

• One pt with bowel obstruction

• Hernia Repair 1.3 yrs later

– LVHR in 8 (31%)

– Open (STOPPA) in 19 (69%)

OUTCOMES

-F/U 20 months

-NO Recurrence

Ventral Hernias in Bariatric Surgery is it Safe to Deferred VHR?

• Retrospective review

• 85 pts (65 umbilical or small ventral hernia)

• BMI >35

– Mean 51

• LVH 3 groups

– Primary Repair 59 (70%)

– Mesh 12 Synthetic/Bio (14%)

– Deferred Repair 14 (18%) Repair of VH in Morbid Obese pts undergoing Gastric Bypass should not be deferredEid et al Surg Endos

• OutcomesPrimary Repair

30 month F/U recurrence 22%

Biologic Mesh

F/U 13 months NO recurrence

Deferred Repair

5 pts w/SBO

• Conclusions:– Primary Repair High Failure Rate

– Do NOT Deferred if LOA

Conclusion

Obesity is a risk factor for hernia failure

Medical guidance may improve outcomes

Laparoscopic is safe• Don’t force it-contraindications exist

Open repair is excellent option

Staged repair may improve outcomes

Primary repair high failure rates